Small Bodies, Big Differences: A Neglected Principle in Paediatric Medicine

Written By Maureen Oluwaseun Adeboye

Children are not miniature adults. Why do I choose to tell this story now? Why should you care? Well, recently, I read about the tragic passing of a 21-month-old in Nigeria who died after alleged oversedation. I do not know the details and as such this is not a commentary on the case. The story made the headlines given the child’s caregiver is a well-known author. This unfortunate story resurfaced a truth we cannot repeat enough: children are not miniature adults whose doses can be halved by feel.

As this story has shown, miscalculations can have outsized consequences in paediatrics. Why? Because children are not miniature adults.

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For many medical students like myself, this mantra has become a cliché of paediatrics postings but it quickly comes to life when proven. The consequence for realizing this is often dire, like the case I mentioned at the start of this piece. Even within paediatrics, neonates (babies who are less than a month old), infants (babies who are less than a year old), toddlers, children, and adolescents have distinct anatomy, physiology, biochemistry, and disease patterns. These differences change everything, from risk factors and symptom profiles to causative organisms and safe therapies. That distinction becomes critical with medicines. Take seizures for example. While the treatment principle is the same, stopping them promptly, the first-line therapy is not. For neonates we prefer phenobarbital and not diazepam, because drug handling and toxicity differ in the first weeks of life. Multiple modern care pathways and guidance from the International League Against Epilepsy support phenobarbital as first-line therapy in this age group. Similarly, for antibiotics the widely used ceftriaxone can displace bilirubin, a yellow/green product in blood, from albumin, the most abundant carrying protein in our blood. This means that in neonates, ceftriaxone can increase the risk of bilirubin encephalopathy (an illness where bilirubin gets to deep areas in the brain). As such, many neonatal guidelines recommend avoidance. Newer clinical evidence suggests circumstances where it might be safe in carefully selected term infants with mild, resolving jaundice, underscoring the need for precise patient selection and dosing.

Children are equally different from adults, in that they often cannot advocate for themselves. Their stories are told by parents or other caregivers. For paediatricians, this is normal. For other healthcare workers, it might be challenging. This is particularly true in many low- and middle-income settings where the same clinicians care for adults and children. Understandably, they may overlook these differences amid crowding and staff shortages - the child becomes “just another patient” in a very long queue.

This is where pause becomes a clinical skill. Check the medication, check the dose, then when you are done, check it again. Do not rush past a child because an adult is waiting. Assess and recognise the danger signs. Do not let time pressure or experience replace protocol. Above all, do not practice by intuition alone. When in doubt, seek help from colleagues and consult formularies because dosing in paediatrics is not estimation; it is a calculation—by age, by weight, and sometimes by body surface area.

The scale of medication harm makes this more than an individual clinical issue. The World Health Organization estimates that unsafe medication practices cost tens of billions of dollars globally each year and remain a leading cause of avoidable harm, prompting its Medication Without Harm challenge to halve severe preventable medication-related injury. At the same time, global child survival has stalled: millions of children under five still die each year, with nearly half of those deaths occurring in the neonatal period. Sub-Saharan Africa bears a disproportionate share of this burden. Paediatric medication errors and adverse drug reactions are consistently reported at higher rates than in adults, with dosing mistakes among the most frequent contributors. Studies from African hospitals echo this pattern, documenting high error rates driven by system pressures rather than individual negligence. These figures do not indict clinicians; they indict systems that fail to match complexity with safeguards.

Photo Credit: Rewired Digital

A practical response is to treat paediatric medication safety as a bundle of standard habits rather than a collection of optional extras. At its core is disciplined standardisation: every paediatric chart displays weight in kilograms; dosing is explicitly calculated per kilogram; high-risk and neonatal medications are independently double-checked; and visual, weight-based reference tools are immediately accessible at the bedside. Where digital infrastructure exists, decision support and e-prescribing can reinforce safe limits; where it does not, structured paper order sets and pharmacist review provide meaningful protection. Formularies aligned with child-appropriate essential medicines ensure that clinicians are not forced to improvise with adult formulations. Continuous measurement—tracking dosing errors, adverse drug reactions, and near misses in a non-punitive environment—turns mistakes into learning rather than blame.

This approach aligns with broader global priorities. The WHO–UNICEF–Lancet Commission argued that child survival depends not only on access but on the quality and safety of care, a message echoed in global patient safety frameworks and the child survival targets embedded in the Sustainable Development Goals. Regionally, the emerging African Medicines Agency offers an opportunity to harmonise paediatric labelling, dosing standards, and child-appropriate formulations across borders. National quality strategies and newborn initiatives in several African countries demonstrate that systematic, standards-driven reform can translate into measurable survival gains. Embedding medication safety into these efforts is a logical and urgent next step.

Predictably, objections arise. Some argue that hospitals lack digital tools or enough pharmacists. Yet many of the most effective safeguards are low-tech: weight documentation, structured dosing charts, and independent checks cost little and save lives. Others worry that safety bundles slow workflow. In reality, standardisation reduces rework, prevents crises, and ultimately conserves time. Concerns about mixed evidence for specific drugs are precisely why age-specific protocols must be explicit and regularly updated. Fear of blame can suppress reporting, but a learning-focused safety culture—explicitly promoted in global patient safety agendas—protects both staff and patients.

“Paediatric care demands humility, precision, patience, and respect for biological difference.”
— Maureen Oluwaseun Adeboye.

For the frontline clinician, the discipline reduces to a simple mental checklist repeated every time: What is the exact calculated dose? Is the formulation and route appropriate for this age? Has a high-risk or neonatal dose been double-checked? Is the drug developmentally safe for this patient? These questions are not admissions of uncertainty; they are hallmarks of professional vigilance.

Paediatric care demands humility, precision, patience, and respect for biological difference. For many children, safety depends entirely on the vigilance of the adults entrusted with their care. If there is anything to remember, let it be this, repeated until it becomes reflex: children are NOT small adults.

Sources

Maureen Oluwaseun Adeboye

Maureen Oluwaseun Adeboye is an aspiring paediatrician, currently pursuing her medical degree at the University of Ghana Medical School. 

She is deeply passionate about child health and advocacy on all levels, from empowering mothers and caregivers with accurate health information, to promoting access to relevant resources for diagnosis and treatment, all in a bid to improve the quality of care available to children especially in low and middle income societies.

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